Durable Medical Equipment, Prosthetics, Orthotics, and Supplies When billing for
Out-Patient Surgery-
Ocean View School District et al. v. Workers' Compensation Appeals Board B202630 Second Appellate District, Division Six
Nov. 26, 2007
8 Cal. Code Reg. § 9789.38(b), ''Determination of hospital outpatient prospective payment rates: Included costs,'' provides ''The
prospective payment system establishes a national payment rate, standardized for geographic wage differences, that includes operating
and capital-related costs that are directly related and integral to performing a procedure or furnishing a service on an outpatient basis. In
general, these costs include, but are not limited to . . . '' (subsection 10) ''Durable medical equipment that is implantable.''
Section 9789.38 adopts the federal regulation (42 C.F.R. § 419.2) which addresses the practices of outpatient facilities. It does not
address the providers of durable medical equipment or restrict the number of mechanisms for billing for durable medical equipment that
is implantable.
Seeking reimbursement for the battery is not an attempt to ''enmesh the Petitioner in an internal billing dispute between the Lien
Claimant and the Outpatient Facility There is no internal billing dispute. If petitioner contemplated that the battery was included
when paying the surgery center, it was due to a failure to review and contest the Spanish Hills bill.
In this case it is the equipment provider's billing and lien that is in issue. A restriction on the surgery center cannot automatically be
applied to bar recovery from a medical provider that is not subject to that regulation
Out-Patient Surgery-
Ocean View School District et al. v. Workers' Compensation Appeals Board B202630 Second Appellate District, Division Six
Nov. 26, 2007
8 Cal. Code Reg. § 9789.38(b), ''Determination of hospital outpatient prospective payment rates: Included costs,'' provides ''The
prospective payment system establishes a national payment rate, standardized for geographic wage differences, that includes operating
and capital-related costs that are directly related and integral to performing a procedure or furnishing a service on an outpatient basis. In
general, these costs include, but are not limited to . . . '' (subsection 10) ''Durable medical equipment that is implantable.''
Section 9789.38 adopts the federal regulation (42 C.F.R. § 419.2) which addresses the practices of outpatient facilities. It does not
address the providers of durable medical equipment or restrict the number of mechanisms for billing for durable medical equipment that
is implantable.
Seeking reimbursement for the battery is not an attempt to ''enmesh the Petitioner in an internal billing dispute between the Lien
Claimant and the Outpatient Facility There is no internal billing dispute. If petitioner contemplated that the battery was included
when paying the surgery center, it was due to a failure to review and contest the Spanish Hills bill.
In this case it is the equipment provider's billing and lien that is in issue. A restriction on the surgery center cannot automatically be
applied to bar recovery from a medical provider that is not subject to that regulation
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